Dental Medical History Patient Name *Birth Date *Date Created * Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have important interrelationship with the dentistry you will receive. Thank you for answering the following questions.Physicians CareAre you under a physicians care now? *YesNoIf yes, please specify... HospitalizationHave you ever been hospitalized or had a major operation? *YesNoIf yes, please specify... Head/Neck InjuryHave you ever had a serious head or neck injury? *YesNoIf yes, please specify... MedicationAre you taking any medications, pills, or drugs? *YesNoIf yes, please specify... Do you take, or have you taken, Phen-Fen or Redux? (weight loss medication) *YesNoIf yes, please specify... Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? *YesNoIf yes, please specify... DietAre you on a special diet? ie. gluclose free, sugar *YesNoIf yes, please specify... TobaccoDo you use tobacco? *YesNoIf yes, please specify... Controlled SubstancesDo you use controlled substances? *YesNoIf yes, please specify... AspirinDo you take aspirin? *YesNoIf yes, Dose and Frequency? Women: Are you... Pregnant? Trying to get pregnant?Nursing?Taking oral contraceptives?Are you allergic to the any of the following? AspirinPenicillinCondeineAcryllicMetalLatexSulfa DrugsLocal AnestheticsDo you have, or have you had, any of the following? AIDS/HIVAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsYellow JaundiceCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/DiseasesHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMistral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseComments Agreement and Signature To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is by responsibility to inform the dental office of any changes in medical status.By typing my full name below, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement.Full Name *Date * VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
